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Mental Health Services - Adult Manual

Mental Health Services - Adult Manual

Mental Health Services - Adult Manual

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Enrollment Provider Numbers

Reimbursement for mental health services through Medicaid requires enrollment as a Medicaid provider prior to services being provided. Montana Provider Relations will enroll mental health providers. Information concerning enrollment is available on the Montana Healthcare Programs Provider Information website at http://medicaidprovider.mt.gov. Providers may contact also Provider Relations at 1-800-624-3958 (in/out of state) or 406-442-1837 (Helena). A provider must have an active provider number to submit a claim for reimbursement. Mental health providers must use their National Provider Identifier (NPI) and taxonomy number to bill for services unless they are an atypical mental health provider type. Atypical mental health provider types include group homes and adult foster care. Atypical mental health providers may bill using their NPI and taxonomy number or the Atypical Provider Identifier (API) number assigned to them by Montana Provider Relations upon enrollment.

Pharmacy providers and prescribers should also enroll as Mental Health Service Plan (MHSP) providers to be eligible for reimbursement for services provided under the MHSP program. Call Provider Relations for information.

Some providers may have different provider numbers assigned for different types of mental health services they are providing. If you do have multiple provider numbers, be sure to use the correct provider number for the services being billed.

Coding Requirements

When coding for Montana Medicaid, be aware that Current Procedural Terminology (CPT) codes and modifiers, including their respective definitions, are developed by the American Medical Association for providers to describe their services numerically for claim submission to insurers.

Montana DPHHS requires the use of uniform procedure and diagnosis coding on all claims. The procedure code must accurately reflect the time spent with the member.

The Department’s goal is to pay claims as quickly and efficiently as possible. To attain this goal, a computer processes claims. This automated method does not include review by medical personnel or detailed evaluation for appropriate billing procedures.

The automated system detects many billing errors and denies claims accordingly. However, this process is not conclusive. Providers are responsible for billing their services correctly. Standard use of coding conventions, particularly those established in the current editions of the ICD diagnosis, CPT, and HCPCS manuals are required of the provider when billing Medicaid. Providers should become familiar with these manuals because DPHHS relies on them when setting its coding policies.

ARM 37.85.413 states that employees of the Department, or of any contractor or agent of the Department, may give a provider general information as to what codes are available for billing under Medicaid for a particular service or item being provided. However, the provider retains responsibility for selecting and submitting the proper code to describe the service or item provided. If an employee of the Department or of a contractor or agent of the Department suggests, recommends, or directs the provider to use a particular code from the choices available or gives other specific coding advice, the Adult Mental Health Replacement Page, March 2017 provider may not rely on such advice unless the advice is provided in writing before the provider submits a claim for the service or item.

Do not assume that payment of a claim means the service was billed or paid correctly. All claims are subject to post-payment review and possible recovery of overpayments.

Providers are required to provide services in accordance with federal regulations, Montana state law, Administrative Rules, and any applicable licensure standards. In the event of a conflict between federal regulations, Montana state law, Administrative Rules, or any applicable licensure standards and this manual, the federal regulations will prevail.

The Department only makes payment for services which are medically necessary as determined by the Department or by the designated review organization.

Claims for individuals who are dually Medicare/Medicaid eligible will be paid taking into consideration the psychiatric reduction from Medicare. Medicare mental health crossovers will price at the lower of the Medicare allowed minus what Medicare has paid or the Medicaid allowed minus what Medicare paid.

Surveillance/Utilization Review

Payment of a claim does not mean it was paid correctly. Periodic retrospective reviews are performed, which may lead to the discovery of incorrect billing or incorrect payment. The Department is charged by federal and state law to identify, investigate, and refer to the Medicaid Fraud Control Unit of the Department of Justice all cases of suspected fraud or abuse in Medicaid by either providers or members. Refer to the General Information for Providers manual for additional information and requirements regarding surveillance/utilization review.

Coverage

Mental health services delivered by the provider types listed below are covered under Montana Medicaid. For detailed information on reimbursed services, see the appropriate provider category under the Services section of this manual.

Claims for services that require prior authorization must have the prior authorization number indicated in the appropriate field on the claim form. Providers must bill Medicaid according to the information supplied on the prior authorization. Each line on the claim must match the line information on the authorization with respect to dates of service, procedure code, and units of service.

For providers who bill using the CMS-1500 claim form, if the prior authorization issued has 3 lines of service, the provider must bill with 3 individual lines on the claim form that match the 3 lines on the prior authorization. A prior authorization number may have up to 21 claim lines.

For providers who bill using the UB-04 claim form, if the prior authorization issued has three lines of service, the provider must bill three individual UB-04 claim forms for each line of service indicated on the prior authorization.

Another option is to call the Integrated Voice Response (IVR) at 1-800-714-0060 or FaxBack at 1-800-714-0075. IVR indicates whether a Medicaid or MHSP member has eligibility for a particular date of service. Providers must have their NPI/API, member identification number, and date of service available. FaxBack faxes a report of the member’s eligibility including managed care details, insurance coverage, Medicare coverage, etc. To sign up for FaxBack, call Montana Provider Relations at 1-800-624-3958 (in/out of state) or 406-442-1837 (Helena). Providers must have their NPI/API and fax number ready when they call.

Providers are given an audit number when contacting Montana Provider Relations and IVR for eligibility. Providers are responsible for keeping the audit number on file in case there are discrepancies regarding eligibility during claims processing.

Medicaid Members on Passport

Medicaid members who are covered through Passport do not need a referral from their primary care provider to access mental health services. These mental health services will be paid through the Medicaid fee-for-service mental health program. All requirements of the mental health program, including prior authorization, apply to Passport enrollees obtaining mental health care.

Services

Inpatient Hospital

Requirements
Inpatient hospital services are those items and services ordinarily furnished by a hospital for the care and treatment of inpatients. Services must be provided under the direction of a licensed physician in a facility maintained primarily for treatment and care of patients with disorders other than tuberculosis or mental illness. The facility must be currently licensed by the designated state licensing authority in the state where the facility is located and must meet the requirements for participation in Medicaid as a hospital.

Outpatient Hospital

Requirements
Outpatient hospital services are those preventive, diagnostic, therapeutic, rehabilitative, and palliative items or services provided to an outpatient under the direction of a physician, dentist, or other practitioner. Outpatient hospital services must be provided by a facility licensed as a hospital by the designated state licensing authority in the state where the facility is located and that meets the requirements for participation in Medicaid as a hospital.

Outpatient means a person who has not been admitted by a hospital as an inpatient, who is expected by the hospital to receive services for less than 24 hours, who is registered in the hospital records as an outpatient, and who receives outpatient hospital services other than supplies alone.

Billing/Reimbursement
Outpatient hospital services for mental health diagnosis will be reimbursed using the Outpatient Prospective Payment System (OPPS), which is based on the Ambulatory Payment Classification (APC), if applicable, or based on a fee established by the Department for out-of-state hospitals or in-state PPS hospitals. For in-state critical access hospitals (CAHs), outpatient hospital services will be reimbursed based on a hospital specific percent of charges. Claims must be submitted on a UB-04 form.

Partial Hospitalization

Requirements
Full-day programs require provision of services for a minimum of 6 hours per day, 5 days per week. Half-day programs require provision of services for a minimum of 4–6 hours per day, 4 days per week.

Partial hospitalization is provided by programs that are operated by a hospital with a distinct psychiatric unit and are co-located with that hospital such that in an emergency a patient of the partial hospitalization program can be transported to the hospital’s inpatient psychiatric unit within 15 minutes. Partial hospitalization programs serve primarily individuals being discharged from inpatient psychiatric treatment and are designed to stabilize patients sufficiently to allow discharge to a less intensive level of care, on average after 15 or fewer treatment days.

Partial hospitalization services must be billed under Revenue Code 912 and must include a Montana-specific procedure code in the HCPCS field (Form Locator 44) on the UB-04 form. For partial hospitalization services, use Code H0035 with the appropriate modifier.

Reimbursement for partial hospitalization is based on a bundled rate that includes all of the services associated with the psychiatric diagnosis. These services include psychologists, social workers and licensed professional counselors, and medications received during treatment. Physicians and psychiatrists are the only providers allowed to bill separately for their services.

Institution for Mental Disease

Requirements
Institution for mental disease means a hospital, nursing facility, or other facility with more than 16 beds which the Department has determined is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

An institution for mental disease, as a condition of participation in the Montana Medicaid program, must be a nursing facility that meets the following requirements (ARM 37.88.1405):

Complies with the requirements of ARM 37.40.306 for Medicaid nursing facility service providers;

Has been determined by the Department, in accordance with ARM 37.88.1402, to be an institution for mental diseases;

Complies with ARM 37.40.352 regarding utilization review and quality of care for nursing facilities; and

Enters into and maintains a written agreement with the Department that specifies the respective responsibilities of the Department and the provider.

Person Centered Plan
Institutions for mental diseases providing services must provide for and maintain recorded individual plans for treatment and care to ensure that institutional care maintains the member at, or restores the member to, the greatest possible degree of health and independent functioning. The plans must include:

Designation for needed care at a level higher than personal care;

An initial review of the member’s medical, psychiatric and social needs within 30 days after the date of admission;

Periodic review of the member’s medical, psychiatric and social needs;

A determination at least every 90 days of the member’s need for continued higher level of care and for alternative care arrangements;

Appropriate medical treatment in the facility; and

Appropriate social services.

Billing/Reimbursement
The Montana Medicaid program reimburses for services provided for members age 65 or over or members under 21 receiving nursing facility services in a nursing facility that the Department has determined to be an institution for mental diseases. Reimbursement calculation will be in accordance with the rules adopted by the Department for institutions for mental diseases (ARM 37.88.1410).

Providers must bill for all services and supplies in accordance with the provisions of ARM 37.85.406. The Department pays a provider on a monthly basis the amount determined under rules established by the Department upon receipt of an appropriate billing which reports the number of patient days provided to authorized members during the billing period. Institution for mental disease providers will bill on the Department MA-3/TAD for these per diem amounts.

Mental Health Centers

Definitions and Requirements
A licensed mental health center (MHC) is a facility providing services for the prevention or diagnosis of mental health issues, the care and treatment of mental health issues, the rehabilitation of individuals with mental health issues, or any combination of these services.

For an MHC to be licensed, the following services must be provided: crisis telephone services; medication management; outpatient therapy; community-based psychiatric rehabilitation and support; and substance use related services. Beyond the required substance use-related services defined in ARM 37.106.1902, substance use-related treatment is not reimbursed by the Mental Health Services Bureau.

An MHC with an appropriate license endorsement may provide one or more of the following services: adult targeted case management; adult day treatment; adult foster care; mental health group home; an inpatient crisis stabilization facility; or an outpatient crisis facility.

Benefits and Limitations
Mental health center services include the following:

Practitioner services include inpatient and outpatient therapy provided by licensed mental health professionals, including physicians, mid-level practitioners, psychologists, social workers, and licensed professional counselors. Practitioner services are subject to the respective requirements of each provider type. Group therapy can have no more than 8 members.

In-training practitioner services provided under the supervision of a licensed practitioner by an individual who has completed all academic requirements for licensure. Services are subject to the same requirements that apply to licensed practitioners.

Day treatment

Community-based psychiatric and rehabilitation support

Crisis intervention facility

Group home and foster home services

Mental health group home therapeutic home visits and mental health foster care therapeutic home visits. No more than 14 days per individual in each rate year will be allowed for therapeutic home visits. For purposes of the 14-day limit, all therapeutic home visits must be included.

Intensive community-based rehabilitation facility

Program of Assertive Community Treatment (PACT)

Targeted case management

Illness management and recovery

Each MHC shall employ or contract with an administrator and medical director. This requirement does not mean the medical director must be an employee of the MHC or be used on a full-time basis or be present in the facility during all hours of service provided. However, each member’s care must be under the supervision of a physician directly affiliated with the MHC.

To meet this requirement, a physician must see the member at least once and prescribe the type of care to be provided. If the services prescribed are not limited by the prescription, the physician must periodically review the need for continued care. Although the physician does not have to be on the premises when the member is receiving covered services, the physician must assume professional responsibility for the services provided and assure the services are medically necessary and appropriate.

Billing/Reimbursement
MHCs are required to bill CPT codes for services provided by physicians, mid-level practitioners, psychologists, social workers, professional counselors, and in-training practitioners (under clinical supervision). Reimbursement will be according to the Department’s Resource-Based Relative Value Scale (RBRVS) fee schedule, adjusted for the provider type.

Refer to the appropriate provider type descriptions in the Services section of this manual for additional information.

Psychiatrists and other physicians billing with a MHC provider number are eligible for reimbursement for evaluation and management (E/M) services provided to Medicaid beneficiaries. Use the applicable CPT codes for complete descriptions and coding guidelines for E/M services.

Providers should submit their usual and customary charge for the crisis response service or initial intake examination they are providing. Federal guidelines require that a provider’s usual and customary charge for this particular service must not be more than the provider would charge a private-pay patient or another payer.

Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims being denied. DSM codes are not valid in the Medicaid claims processing system.

Physician Services

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form.

Psychiatrists

Physicians who practice psychiatry must be board certified or board eligible and licensed by the State of Montana or in the state where they maintain their practice and enrolled as a psychiatrist with Montana Medicaid.

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form.

Mid-Level Practitioners

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form. Refer to the Physician-Related Services manual for additional billing instructions.

Psychologist Services

Psychologist services are those services provided by a licensed psychologist that are within the scope of the practices of the profession as provided for in Title 37, Chapter 17, of Montana Code Annotated (MCA).

Psychologists are required to bill on a CMS-1500 form using applicable CPT codes for services.

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form. Refer to the Physician-Related Services manual for additional billing instructions.

Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims being denied. DSM codes are not valid in the Medicaid claims processing system.

A family therapy session must not be billed under more than one family member’s Medicaid number. The family member must be Medicaid-eligible on the date of service.

Medicaid covers inpatient psychologist services as part of the inpatient payment rate in the following circumstances:

When services are provided by psychologists who are employed by the hospital or under contract with the hospital involving consideration; and

When services are part of discharge planning as required in 42 CFR 482.21(b) or other services,such as group therapy, which are required as part of licensure or certification of the hospital.

All other inpatient services provided by a psychologist are a benefit, up to the limits specified in this manual.

Licensed Clinical Social Worker (LCSW)

Those services provided by an LCSW that are within the scope of the practice of the profession as provided for in Title 37, Chapter 2, of the Montana Code Annotated (MCA).
Social workers are required to bill on a CMS-1500 form using applicable CPT codes for services.
Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims being denied. DSM codes are not valid in the Medicaid claims processing system.

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form. Refer to the Physician-Related Services manual for additional billing instructions.

A family therapy session must not be billed under more than one family member’s Medicaid number. The family member must be Medicaid-eligible on the date of service.

Medicaid covers inpatient social worker services as part of the inpatient payment rate in the following circumstances:

When services are provided by a social workers who is employed by the hospital or under contract with the hospital involving consideration; and

When services are part of discharge planning as required in 42 CFR 482.21(b) or other services,such as group therapy, which are required as part of licensure or certification of the hospital.

All other inpatient services provided by a social worker are a benefit, up to the limits specified in this manual.

Licensed Clinical Professional Counselor (LCPC)

Licensed clinical professional counselor (LCPC) services are those services provided by an LCPC that are within the scope of the practices of the profession as provided for in Title 37, Chapter 23, Montana Code Annotated (MCA).

Professional counselors are required to bill on a CMS-1500 form using applicable CPT codes for services.

Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims denial. DSM codes are not valid in the Medicaid claims processing system.

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form. Refer to the Physician-Related Services manual for additional billing instructions.

A family therapy session must not be billed under more than one family member’s Medicaid number. The family member must be Medicaid-eligible on the date of service.

Medicaid covers inpatient professional counselor services as part of the inpatient payment rate in the following circumstances:

When services are provided by a professional counselor who is employed by the hospital or under contract with the hospital involving consideration; and

When services are part of discharge planning as required in 42 CFR 482.21(b) or other services,such as group therapy, which are required as part of licensure or certification of the hospital.

All other inpatient services provided by a professional counselor are a benefit, up to the limits specified in this manual.

Inpatient Psychiatric Services

(for persons age 18 to age 21)

Inpatient Psychiatric Hospitalization
Inpatient psychiatric services are services provided in an inpatient hospital facility. A Certificate of Need (CON) is not required for persons who are age 18 to 21 years of age.
Prior authorization is not required prior to the member’s admission to inpatient psychiatric services.

Billing/Reimbursement
Payment for inpatient psychiatric services provided outside the state of Montana will be made only under the conditions specified in ARM 37.86.2801. Reimbursement for inpatient psychiatric services provided to Montana Medicaid members in facilities located outside the state of Montana will be as provided in ARM 37.86.2947.

Targeted case management services for adults (age 18 and older) with SDMI are case management services provided by a licensed mental health center in accordance with these rules and the provisions of Title 50, Chapter 5, Part 2, MCA.

A member may temporarily receive case management services from more than one case management provider. Refer to ARM 37.86.3305 for the criteria.

Definition
Targeted case management is defined as services that assist individuals eligible in gaining access to needed, medical, educational, and other services.

Covered Services and Requirements
Case management activities for adults with severe and disabling mental illness include the following assistance:

Comprehensive assessment and reassessment at least once every 90 days of an eligible member to determine service needs, including activities that focus on needs identification determination of the need for any medical, educational, social, or other services.

These assessment activities include the following:

Taking member history;

Identifying the needs of the individual, and completing related documentation; and

Gathering necessary information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to make a complete assessment of the eligible member.

Development (and periodic revision) of a specific care plan based on the information collected through the assessment that:

Specific goals and actions to address the medical, social and educational, and other services needed by the eligible member;

Includes activities such as ensuring the active participation of the eligible member and working with the member (or the member’s authorized healthcare decision maker) and others to develop those goals; and

Identifies a course of action to respond to the assessed needs of the eligible member.

Referral and related activities (such as making referrals and scheduling appointments for the member) to help the eligible member obtain needed services, including activities to help link the member with medical, social and educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and

Monitoring and follow-up activities, including activities and contacts to ensure that the care plan is effectively implemented and addresses the needs of the eligible member. Activity may be with the member, family members, service providers, or other entities or members and conducted as frequently as necessary, and at least once every 90 days, to help determine whether the following conditions are met:

Services are being furnished in accordance with the member’s care plan;

Services in the care plan are adequate to meet the needs of the member;

There are changes in the needs or status of the eligible member. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

Case management may include contacts with non-eligible members that are directly related to the identification of the eligible member’s needs and care, for the purpose of helping the eligible member access services, identifying needs and supports to assist the eligible member in obtaining services, providing case managers with useful feedback, alerting case managers to changes in the eligible member's needs, and averting crisis.

Case management does not include the following:

Non-Medicaid individuals can receive outreach, application, and referral activities;however, these activities are not allowable as case management services, rather they are an administrative function.

Direct medical services including counseling or the transportation or escort of members;

Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities;

The writing, recording, or entering case notes for the member’s file;

Coordination of the investigation of any suspected abuse, neglect, and/or exploitation cases;

Travel to and from member activities; and

Any service less than 8 minutes duration if it is the only service provided that day and any service that does not incorporate the allowable targeted case management components, even if written into the individualized care plan.

Provider Requirements
All providers of service must maintain records which fully demonstrate the extent, nature, and medical necessity of services and items provided to Montana Medicaid members. The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements. Refer to ARM 37.85.410 for medical necessity criteria and ARM 37.85.414 for record keeping and documentation requirements.

TCM for adults with SDMI must be provided by a licensed MHC with a license endorsement permitting the MHC to provide TCM. Licensed MHCs that have an endorsement to provide TCM services must enroll with Montana Medicaid as a TCM provider of mental health services before any case management claims can be paid. MHCs providing TCM services to adults with SDMI must have a program supervisor and employ case managers who have a Bachelor’s degree in a human services field with at least one year of full-time experience serving individuals with SDMI. Individuals with other educational background, who have developed the necessary skills, may also be employed as case managers. The MHC case management position description must contain equivalency provisions. The availability of case management services may not be made contingent upon a member’s willingness to receive other services.

Billing/Reimbursement
TCM services for adults with SDMI will be reimbursed according to the Department’s fee schedule. The Montana Medicaid program will not pay more than one provider for intensive case management services for the same period of time for the same member.

Case managers must inform eligible individuals they have the right to refuse case management at the time of eligibility determination and annually thereafter at the time of reassessment; and providers must document in the case record that the individual has been informed and if the individual has refused services. Refer to ARM 37.85.410 and ARM 37.85.414.

All providers of service must maintain records which fully demonstrate the extent, nature, and medical necessity of services and items provided to members. The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements. The amount, duration, and scope of the case management activities must be documented in a member’s person centered plan of care which includes case management activities prior to and post-discharge, to facilitate a successful transition to the community.

The Department will pay the lower of the provider’s actual submitted charge or the Department’s fee schedule for case management services for adults with SDMI. Case management services for adults will be reimbursed under the following procedure code by Montana Medicaid. They must be billed on the CMS-1500:

Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims denial. DSM codes are not valid in the Medicaid claims processing system.

Pharmacy Services

Medicaid Pharmacy Program
There is no change in processing pharmacy claims for Medicaid-eligible members. Refer to the Medicaid Prescription Drug Program manual for billing and reimbursement instructions.

To request prior authorization, providers must submit the information asked for on the Request for Medicaid Drug Prior Authorization form to the Drug Prior Authorization Unit.

The prescriber (e.g., physician) or pharmacy provider may submit requests by mail, telephone, or fax to:

Requests will be reviewed and approvals or denials will be made, in most cases, immediately. Decisions on requests requiring further peer review because of unusual or special circumstances will be made within 24 hours. Requests received after the Drug Prior Authorization Unit’s regular working hours of 8 a.m. to 5 p.m., Monday through Friday or on weekends or holidays will be considered to be received at the start of the next working day.

If an after-hours, weekend, or holiday request is for an emergency situation, an emergency 72-hour supply may be dispensed by using 3 in the Days Supply field and Medical Certification Code 8 in the PA/MC code field. Payment will be authorized for these emergency supplies.

To receive payment for drugs requiring prior authorization, pharmacies must obtain approval from the Drug Prior Authorization Unit prior to dispensing the drug.

Coverage
Prescriptions are limited to a 34-day supply. Refills may be dispensed after 75% of a previous dispensing of the same prescription has been used, if taken according to the doctor’s orders. Exceptions to this refill rule must be authorized by the Department.

Reimbursement
Reimbursement information is available in the Prescription Drug Program manual.

Billing
Billing information is available in the Prescription Drug Program manual. If you have questions or experience problems, call Montana Provider Relations:

1 (800) 624-3958 (In/Out of state)
(406) 442-1837 (Helena)

Copayment
Preferred generic drugs
Preferred brand drugs only with generic available
Brand name drugs with no generic
Generic non-preferred
Non-preferred brand
No copayment for Clozaril and Clozapine

The Medicaid copayments are 5% of the allowable amount between $1 and $5 with a maximum cost share of $5 per prescription, and $25 per month.

Preferred products are drugs listed on the formulary for which the State of Montana has a rebate agreement with the drug manufacturer.

Indian Health Service (IHS)
Indian Health Service providers may be reimbursed for mental health services for Medicaid members. Indian Health Service providers should bill using the mental health encounter Revenue Code 513 or the inpatient physician services Revenue Code 987.

Administrative Rules of Montana (ARM)

The rules published by the executive departments and agencies of the state government.

Adult

A person who is 18 years or older. (Note: Children’s Mental Health continues to cover a person 18–21 who is enrolled in secondary school.)

Adult Day Treatment

A program that, in accordance with mental health center license requirements, provides a variety of mental health services to adults with severe disabling mental illness.

Allowed Amount

provider for a healthcare service as determined by Medicaid or another payer. Other cost factors (such as cost sharing, TPL, or incurment) are often deducted from the allowed amount before final payment. Medicaid’s allowed amount for each covered service is listed on the Department fee schedule.

Assignment of Benefits

A voluntary decision by the member to have insurance benefits paid directly to the provider rather than to the member. The act requires the signing of a form for the purpose. The provider is not obligated to accept an assignment of benefits. However, the provider may require assignment in order to protect the provider’s revenue.

Authorization

An official approval for action taken for, or on behalf of, a Medicaid member. This approval is only valid if the member is eligible on the date of service.

Centers for Medicare and Medicaid Services (CMS)

Administers the Medicare program and oversees the state Medicaid programs.

Clean Claim

A claim that can be processed without additional information from or action by the provider of the service.

Code of Federal Regulations (CFR)

Rules published by executive departments and agencies of the federal government.

Coinsurance

The member’s financial responsibility for a medical bill as assigned by Medicaid or Medicare (usually a percentage). Medicaid coinsurance is usually 5 percent of the Medicaid allowed amount, and Medicare coinsurance is usually 20 percent of the Medicare allowed amount.

Community-Based Psychiatric Rehabilitation and Support

Services provided in home, school, workplace, and community settings for adults with severe and disabling mental illness and youth with serious emotional disturbance.

Services are provided by trained mental health personnel under the direction of and according to individualized treatment plans prepared by licensed professionals. The services are provided outside of normal clinical or mental health program settings and are designed to assist individuals in developing the skills, behaviors, and emotional stability necessary to live successfully in the community.

Community-based psychiatric rehabilitation and support services are provided on a face-to-face basis with the member, family members, teachers, employers or other key individuals in the member’s life when such contacts are clearly necessary to meet goals established in the member’s person centered plan of care.

Copayment

The member’s financial responsibility for a medical bill as assigned by Medicaid (usually a flat fee).

Cost Sharing

The member’s financial responsibility for a medical bill assessed by flat fee or percentage of charges.

Crisis Intervention Services

A program that, in accordance with mental health center license requirements, provides emergency short-term 24-hour care, treatment and supervision in a crisis intervention stabilization facility for persons age 18 or older with mental illness experiencing a mental health crisis.

Crossovers

Claims for members who have both Medicare and Medicaid. These claims may come electronically from Medicare or directly from the provider.

Dialectical Behavior Therapy (DBT)

A treatment designed specifically for individuals with self-harm behavior, such as self-cutting, suicide thoughts, urges to suicide, and suicide attempts. It is based on a bio-social theory that states that problems develop from the interaction of biological factors (physiological makeup) and environmental factors (learning history), which together create difficulty managing emotions. Core treatment techniques are problem solving, exposure techniques, skills training, contingency management, and cognitive modification. The four primary modes of treatment are individual therapy, group skills training, and phone coaching, along with therapist consultation.

Department

The Montana Department of Public Health and Human Services or its agents, including but not limited to parties under contract to perform audit services, claim processing, and utilization review.

DPHHS, State Agency

The Montana Department of Public Health and Human Services (DPHHS or Department) is the designated State Agency that administers the Medicaid program. The Department’s legal authority is contained in Title 53, Chapter 6, MCA. At the Federal level, the legal basis for the program is contained in Title XIX of the Social Security Act and Title 42 of the Code of Federal Regulations (CFR). The program is administered in accordance with the Administrative Rules of Montana (ARM), Title 37, Chapter 86.

Emergency Services

Those services which are required to evaluate and stabilize a medical condition manifesting itself by acute symptoms of sufficient severity (including pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or unborn child) in serious jeopardy, serious impairment to bodily function or serious dysfunction of any bodily organ or part.

Experimental

A noncovered item or service that researchers are studying to investigate its effect on health.

Fiscal Agent

Conduent is the fiscal agent for the State of Montana and processes claims at the Department’s direction and in accordance with ARM 37.86 et seq.

Foster Care for Adults with Severe Disabling Mental Illness

A supervised living environment in a licensed foster home with support services by mental health professionals.

Illness Management and Recovery

An evidence-based practice that gives consumers information about mental illnesses and coping skills to help them manage their illness, develop goals, and make informed decisions about their treatment.

Inpatient Hospital Psychiatric Care

Hospital-based active psychiatric treatment provided under the direction of a physician.

Institution for Mental Diseases

A hospital, nursing facility, or other facility with more than 16 beds which the Department has determined is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services.

An institution for the mentally retarded, including an intermediate care facility for the mentally retarded, is not an institution for mental diseases.

An institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

In making a determination of whether an institution is an institution for mental diseases, the Department shall consider the guidelines set forth in Subsection C of Section 4390 of the State Medicaid manual, but no single guideline or combination of guidelines shall necessarily be determinative.

Intensive Community-Based Rehabilitation Facility

An adult mental health group home that provides medically necessary rehabilitation services to adults with severe and disabling mental illness who have a history of institutional placements due to mental illness and a history of repeated unsuccessful placements in less intensive community-based programs.

In-Training Practitioner Services

Services provided under the supervision of a licensed practitioner by an individual who has completed all academic requirements for licensure as a psychologist, clinical social worker, or licensed professional counselor, and is in the process of completing the supervised experience requirement for licensure.

The in-training practitioner services must be supervised by a licensed practitioner in the same field, and, other than licensure, the services are subject to the same requirements that apply to licensed practitioners. In-training practitioner services are only available through licensed mental health centers.

Medicaid

A program that provides healthcare coverage to specific populations, especially low-income families with children, pregnant women, disabled people, and the elderly. Medicaid is administered by state governments under broad Federal guidelines.

Member

An individual enrolled in a Department medical assistance program.

Mental Health Center Services

Adult day treatment services, community-based psychiatric rehabilitation and support respite care, in-training practitioner services and the therapeutic component of crisis intervention services, foster care for mentally ill adults, and mental health group home services and programs of assertive community treatment, as defined in ARM 37.88.901.

Mental Illness

A mental illness listed as a mental disorder in the current edition of the Diagnostic and Statistical Manual of Mental Diseases but does not include mental retardation, senility, and organic brain syndrome.

Mental Health Group Home Services

A supported living environment provided under a group home endorsed mental health center license and providing independent living and social skills development services.

Mental Health Services Plan (MHSP)

This plan is for individuals who have a severe and disabling mental illness (SDMI), are ineligible for Medicaid, and have a family income that does not exceed an amount established by the Department.

Nursing Facility Services

Services defined in ARM 37.40.302, but not including intermediate care facility services for the persons with intellectual disabilities.

Patient Day

A whole 24-hour period in which a person is present and receiving inpatient psychiatric services or nursing facility services, regardless of payment source. Even though a person may not be present for a whole 24-hour period on the day of admission or the day of death, such day will be considered a patient day. Subject to the limitations and requirements of ARM 37.88.1106, therapeutic home leave days are patient days. The day of discharge is not a patient day for purposes of reimbursement.

Practitioner

Practitioner Services

Services provided by a practitioner who could be covered and reimbursed by the Montana Medicaid program if the individual practitioner were enrolled in the program and provided the services according to applicable Medicaid requirements.

Prior Authorization

The approval process required before certain services or supplies are paid by Medicaid. Prior authorization must be obtained before providing the service or supply.

Private-Pay

When a member chooses to pay for medical services out of his or her own pocket.

Program of Assertive Community Treatment (PACT)

A self-contained clinical team that:

Provides needed treatment, rehabilitation and support services to identified members with severe disabling mental illness;

Minimally refers members to outside service providers;

Provides services on a long-term basis;

Delivers 75% or more of team service time outside program offices;

Serves individuals with severe disabling mental illness (SDMI) who are at least18 years old, have severe symptoms and impairments not effectively treated by other available, less-intensive services, or who have a history of avoiding mental health services;

Provides psychiatric services at the rate of at least 20 hours per week for each70 persons served; and

Maintains a ratio of at least 1 staff person,not including the psychiatrist, for each9 persons served.

Assertive community treatment teams must be approved by the Addictive and Mental Disorders Division.

Provider or Provider of Service

An institution, agency, or person having a signed agreement with the Department to furnish medical care, goods, and/or services to members, and eligible to receive payment from the Department.

Relative Value Scale (RVS)

A numerical scale designed to permit comparisons of appropriate prices for various services. The RVS is made up of the relative value units (RVUs) for all the objects in the class for which it is developed.

Relative Value Unit (RVU)

The numerical value given to each service in a relative value scale.

Remittance Advice

The results of claims processing (including paid, denied, and pending claims) are listed on the remittance advice.

Resident

A person admitted to the provider’s facility who has been present in the facility for at least one 24-hour period.

Resource-Based Relative Value Scale (RBRVS)

A method of determining physicians’ fees based on the time, training, skill, and other factors required to deliver various services.

Retroactive Eligibility

When a member is determined to be eligible for Medicaid effective prior to the current date.

Standard Medicaid

All Medicaid Members are eligible for services in the Standard Medicaid Package if the services is medically necessary. See the General Information for Providers manual.

Third Party Liability (TPL)

Index

Previous editions of this manual contained an index.

This edition has three search options.

1.Search the whole manual. Open the Complete Manual pane. From your keyboard press the Ctrl and F keys at the same time. A search box will appear. Type in a descriptive or key word (for example "Denials". The search box will show all locations where denials discussed in the manual.

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Mental Health Services - Adult Manual

To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

Update Log

Publication History

This publication supersedes all previous Physician-Related Services handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

Updated January 2011, December 2011, March 2012, October 2016,April 2017, and September 2017.

CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.

Enrollment Provider Numbers

Reimbursement for mental health services through Medicaid requires enrollment as a Medicaid provider prior to services being provided. Montana Provider Relations will enroll mental health providers. Information concerning enrollment is available on the Montana Healthcare Programs Provider Information website at http://medicaidprovider.mt.gov. Providers may contact also Provider Relations at 1-800-624-3958 (in/out of state) or 406-442-1837 (Helena). A provider must have an active provider number to submit a claim for reimbursement. Mental health providers must use their National Provider Identifier (NPI) and taxonomy number to bill for services unless they are an atypical mental health provider type. Atypical mental health provider types include group homes and adult foster care. Atypical mental health providers may bill using their NPI and taxonomy number or the Atypical Provider Identifier (API) number assigned to them by Montana Provider Relations upon enrollment.

Pharmacy providers and prescribers should also enroll as Mental Health Service Plan (MHSP) providers to be eligible for reimbursement for services provided under the MHSP program. Call Provider Relations for information.

Some providers may have different provider numbers assigned for different types of mental health services they are providing. If you do have multiple provider numbers, be sure to use the correct provider number for the services being billed.

End of Enrollment Provider Numbers

Coding Requirements

When coding for Montana Medicaid, be aware that Current Procedural Terminology (CPT) codes and modifiers, including their respective definitions, are developed by the American Medical Association for providers to describe their services numerically for claim submission to insurers.

Montana DPHHS requires the use of uniform procedure and diagnosis coding on all claims. The procedure code must accurately reflect the time spent with the patient.

The Department’s goal is to pay claims as quickly and efficiently as possible. To attain this goal, a computer processes claims. This automated method does not include review by medical personnel or detailed evaluation for appropriate billing procedures.

The automated system detects many billing errors and denies claims accordingly. However, this process is not conclusive. Providers are responsible for billing their services correctly. Standard use of coding conventions, particularly those established in the current editions of the ICD diagnosis, CPT, and HCPCS manuals are required of the provider when billing Medicaid. Providers should become familiar with these manuals because DPHHS relies on them when setting its coding policies.

ARM 37.85.413 states that employees of the Department, or of any contractor or agent of the Department, may give a provider general information as to what codes are available for billing under Medicaid for a particular service or item being provided. However, the provider retains responsibility for selecting and submitting the proper code to describe the service or item provided. If an employee of the Department or of a contractor or agent of the Department suggests, recommends, or directs the provider to use a particular code from the choices available or gives other specific coding advice, the Adult Mental Health Replacement Page, March 2017 provider may not rely on such advice unless the advice is provided in writing before the provider submits a claim for the service or item.

Do not assume that payment of a claim means the service was billed or paid correctly. All claims are subject to post-payment review and possible recovery of overpayments.

Providers are required to provide services in accordance with federal regulations, Montana state law, Administrative Rules, and any applicable licensure standards. In the event of a conflict between federal regulations, Montana state law, Administrative Rules, or any applicable licensure standards and this manual, the federal regulations will prevail.

The Department only makes payment for services which are medically necessary as determined by the Department or by the designated review organization.

Claims for individuals who are dually Medicare/Medicaid eligible will be paid taking into consideration the psychiatric reduction from Medicare. Medicare mental health crossovers will price at the lower of the Medicare allowed minus what Medicare has paid or the Medicaid allowed minus what Medicare paid.

End of Third Party Coverage and Medicare Chapter

Surveillance/Utilization Review

Payment of a claim does not mean it was paid correctly. Periodic retrospective reviews are performed, which may lead to the discovery of incorrect billing or incorrect payment. The Department is charged by federal and state law to identify, investigate, and refer to the Medicaid Fraud Control Unit of the Department of Justice all cases of suspected fraud or abuse in Medicaid by either providers or members. Refer to the General Information for Providers manual for additional information and requirements regarding surveillance/utilization review.

End of Surveillance/Utilization Review Chapter

Coverage

Mental health services delivered by the provider types listed below are covered under Montana Medicaid. For detailed information on reimbursed services, see the appropriate provider category under the Services section of this manual.

Claims for services that require prior authorization must have the prior authorization number indicated in the appropriate field on the claim form. Providers must bill Medicaid according to the information supplied on the prior authorization. Each line on the claim must match the line information on the authorization with respect to dates of service, procedure code, and units of service.

For providers who bill using the CMS-1500 claim form, if the prior authorization issued has 3 lines of service, the provider must bill with 3 individual lines on the claim form that match the 3 lines on the prior authorization. A prior authorization number may have up to 21 claim lines.

For providers who bill using the UB-04 claim form, if the prior authorization issued has three lines of service, the provider must bill three individual UB-04 claim forms for each line of service indicated on the prior authorization.

Another option is to call the Integrated Voice Response (IVR) at 1-800-714-0060 or FaxBack at 1-800-714-0075. IVR indicates whether a Medicaid or MHSP member has eligibility for a particular date of service. Providers must have their NPI/API, member identification number, and date of service available. FaxBack faxes a report of the member’s eligibility including managed care details, insurance coverage, Medicare coverage, etc. To sign up for FaxBack, call Montana Provider Relations at 1-800-624-3958 (in/out of state) or 406-442-1837 (Helena). Providers must have their NPI/API and fax number ready when they call.

Providers are given an audit number when contacting Montana Provider Relations and IVR for eligibility. Providers are responsible for keeping the audit number on file in case there are discrepancies regarding eligibility during claims processing.

End of Eligibility Information Chapter

Medicaid Members on Passport

Medicaid members who are covered through Passport do not need a referral from their primary care provider to access mental health services. These mental health services will be paid through the Medicaid fee-for-service mental health program. All requirements of the mental health program, including prior authorization, apply to Passport enrollees obtaining mental health care.

Services

Inpatient Hospital

Requirements
Inpatient hospital services are those items and services ordinarily furnished by a hospital for the care and treatment of inpatients. Services must be provided under the direction of a licensed physician in a facility maintained primarily for treatment and care of patients with disorders other than tuberculosis or mental illness. The facility must be currently licensed by the designated state licensing authority in the state where the facility is located and must meet the requirements for participation in Medicaid as a hospital.

Outpatient Hospital

Requirements
Outpatient hospital services are those preventive, diagnostic, therapeutic, rehabilitative, and palliative items or services provided to an outpatient under the direction of a physician, dentist, or other practitioner. Outpatient hospital services must be provided by a facility licensed as a hospital by the designated state licensing authority in the state where the facility is located and that meets the requirements for participation in Medicaid as a hospital.

Outpatient means a person who has not been admitted by a hospital as an inpatient, who is expected by the hospital to receive services for less than 24 hours, who is registered in the hospital records as an outpatient, and who receives outpatient hospital services other than supplies alone.

Billing/Reimbursement
Outpatient hospital services for mental health diagnosis will be reimbursed using the Outpatient Prospective Payment System (OPPS), which is based on the Ambulatory Payment Classification (APC), if applicable, or based on a fee established by the Department for out-of-state hospitals or in-state PPS hospitals. For in-state critical access hospitals (CAHs), outpatient hospital services will be reimbursed based on a hospital specific percent of charges. Claims must be submitted on a UB-04 form.

Partial Hospitalization

Requirements
Full-day programs require provision of services for a minimum of 6 hours per day, 5 days per week. Half-day programs require provision of services for a minimum of 4–6 hours per day, 4 days per week.

Partial hospitalization is provided by programs that are operated by a hospital with a distinct psychiatric unit and are co-located with that hospital such that in an emergency a patient of the partial hospitalization program can be transported to the hospital’s inpatient psychiatric unit within 15 minutes. Partial hospitalization programs serve primarily individuals being discharged from inpatient psychiatric treatment and are designed to stabilize patients sufficiently to allow discharge to a less intensive level of care, on average after 15 or fewer treatment days.

Partial hospitalization services must be billed under Revenue Code 912 and must include a Montana-specific procedure code in the HCPCS field (Form Locator 44) on the UB-04 form. For partial hospitalization services, use Code H0035 with the appropriate modifier.

Reimbursement for partial hospitalization is based on a bundled rate that includes all of the services associated with the psychiatric diagnosis. These services include psychologists, social workers and licensed professional counselors, and medications received during treatment. Physicians and psychiatrists are the only providers allowed to bill separately for their services.

Institution for Mental Disease

Requirements
Institution for mental disease means a hospital, nursing facility, or other facility with more than 16 beds which the Department has determined is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

An institution for mental disease, as a condition of participation in the Montana Medicaid program, must be a nursing facility that meets the following requirements (ARM 37.88.1405):

Complies with the requirements of ARM 37.40.306 for Medicaid nursing facility service providers;

Has been determined by the Department, in accordance with ARM 37.88.1402, to be an institution for mental diseases;

Complies with ARM 37.40.352 regarding utilization review and quality of care for nursing facilities; and

Enters into and maintains a written agreement with the Department that specifies the respective responsibilities of the Department and the provider.

Person Centered Plan
Institutions for mental diseases providing services must provide for and maintain recorded individual plans for treatment and care to ensure that institutional care maintains the member at, or restores the member to, the greatest possible degree of health and independent functioning. The plans must include:

Designation for needed care at a level higher than personal care;

An initial review of the member’s medical, psychiatric and social needs within 30 days after the date of admission;

Periodic review of the member’s medical, psychiatric and social needs;

A determination at least every 90 days of the member’s need for continued higher level of care and for alternative care arrangements;

Appropriate medical treatment in the facility; and

Appropriate social services.

Billing/Reimbursement
The Montana Medicaid program reimburses for services provided for members age 65 or over or members under 21 receiving nursing facility services in a nursing facility that the Department has determined to be an institution for mental diseases. Reimbursement calculation will be in accordance with the rules adopted by the Department for institutions for mental diseases (ARM 37.88.1410).

Providers must bill for all services and supplies in accordance with the provisions of ARM 37.85.406. The Department pays a provider on a monthly basis the amount determined under rules established by the Department upon receipt of an appropriate billing which reports the number of patient days provided to authorized members during the billing period. Institution for mental disease providers will bill on the Department MA-3/TAD for these per diem amounts.

Mental Health Centers

Definitions and Requirements
A licensed mental health center (MHC) is a facility providing services for the prevention or diagnosis of mental health issues, the care and treatment of mental health issues, the rehabilitation of individuals with mental health issues, or any combination of these services.

For an MHC to be licensed, the following services must be provided: crisis telephone services; medication management; outpatient therapy; community-based psychiatric rehabilitation and support; and substance use related services. Beyond the required substance use-related services defined in ARM 37.106.1902, substance use-related treatment is not reimbursed by the Mental Health Services Bureau.

An MHC with an appropriate license endorsement may provide one or more of the following services: adult targeted case management; adult day treatment; adult foster care; mental health group home; an inpatient crisis stabilization facility; or an outpatient crisis facility.

Benefits and Limitations
Mental health center services include the following:

Practitioner services include inpatient and outpatient therapy provided by licensed mental health professionals, including physicians, mid-level practitioners, psychologists, social workers, and licensed professional counselors. Practitioner services are subject to the respective requirements of each provider type. Group therapy can have no more than 8 members.

In-training practitioner services provided under the supervision of a licensed practitioner by an individual who has completed all academic requirements for licensure. Services are subject to the same requirements that apply to licensed practitioners.

Day treatment

Community-based psychiatric and rehabilitation support

Crisis intervention facility

Group home and foster home services

Mental health group home therapeutic home visits and mental health foster care therapeutic home visits. No more than 14 days per individual in each rate year will be allowed for therapeutic home visits. For purposes of the 14-day limit, all therapeutic home visits must be included.

Intensive community-based rehabilitation facility

Program of Assertive Community Treatment (PACT)

Targeted case management

Illness management and recovery

Each MHC shall employ or contract with an administrator and medical director. This requirement does not mean the medical director must be an employee of the MHC or be used on a full-time basis or be present in the facility during all hours of service provided. However, each member’s care must be under the supervision of a physician directly affiliated with the MHC.

To meet this requirement, a physician must see the member at least once and prescribe the type of care to be provided. If the services prescribed are not limited by the prescription, the physician must periodically review the need for continued care. Although the physician does not have to be on the premises when the member is receiving covered services, the physician must assume professional responsibility for the services provided and assure the services are medically necessary and appropriate.

Billing/Reimbursement
MHCs are required to bill CPT codes for services provided by physicians, mid-level practitioners, psychologists, social workers, professional counselors, and in-training practitioners (under clinical supervision). Reimbursement will be according to the Department’s Resource-Based Relative Value Scale (RBRVS) fee schedule, adjusted for the provider type.

Refer to the appropriate provider type descriptions in the Services section of this manual for additional information.

Psychiatrists and other physicians billing with a MHC provider number are eligible for reimbursement for evaluation and management (E/M) services provided to Medicaid beneficiaries. Use the applicable CPT codes for complete descriptions and coding guidelines for E/M services.

Providers should submit their usual and customary charge for the crisis response service or initial intake examination they are providing. Federal guidelines require that a provider’s usual and customary charge for this particular service must not be more than the provider would charge a private-pay patient or another payer.

Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims being denied. DSM codes are not valid in the Medicaid claims processing system.

Physician Services

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form.

Psychiatrists

Physicians who practice psychiatry must be board certified or board eligible and licensed by the State of Montana or in the state where they maintain their practice and enrolled as a psychiatrist with Montana Medicaid.

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form.

Mid-Level Practitioners

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form. Refer to the Physician-Related Services manual for additional billing instructions.

Psychologist Services

Psychologist services are those services provided by a licensed psychologist that are within the scope of the practices of the profession as provided for in Title 37, Chapter 17, of Montana Code Annotated (MCA).

Psychologists are required to bill on a CMS-1500 form using applicable CPT codes for services.

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form. Refer to the Physician-Related Services manual for additional billing instructions.

Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims being denied. DSM codes are not valid in the Medicaid claims processing system.

A family therapy session must not be billed under more than one family member’s Medicaid number. The family member must be Medicaid-eligible on the date of service.

Medicaid covers inpatient psychologist services as part of the inpatient payment rate in the following circumstances:

When services are provided by psychologists who are employed by the hospital or under contract with the hospital involving consideration; and

When services are part of discharge planning as required in 42 CFR 482.21(b) or other services,such as group therapy, which are required as part of licensure or certification of the hospital.

All other inpatient services provided by a psychologist are a benefit, up to the limits specified in this manual.

Licensed Clinical Social Worker (LCSW)

Those services provided by an LCSW that are within the scope of the practice of the profession as provided for in Title 37, Chapter 2, of the Montana Code Annotated (MCA).
Social workers are required to bill on a CMS-1500 form using applicable CPT codes for services.
Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims being denied. DSM codes are not valid in the Medicaid claims processing system.

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form. Refer to the Physician-Related Services manual for additional billing instructions.

A family therapy session must not be billed under more than one family member’s Medicaid number. The family member must be Medicaid-eligible on the date of service.

Medicaid covers inpatient social worker services as part of the inpatient payment rate in the following circumstances:

When services are provided by a social workers who is employed by the hospital or under contract with the hospital involving consideration; and

When services are part of discharge planning as required in 42 CFR 482.21(b) or other services,such as group therapy, which are required as part of licensure or certification of the hospital.

All other inpatient services provided by a social worker are a benefit, up to the limits specified in this manual.

Licensed Clinical Professional Counselor (LCPC)

Licensed clinical professional counselor (LCPC) services are those services provided by an LCPC that are within the scope of the practices of the profession as provided for in Title 37, Chapter 23, Montana Code Annotated (MCA).

Professional counselors are required to bill on a CMS-1500 form using applicable CPT codes for services.

Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims denial. DSM codes are not valid in the Medicaid claims processing system.

Reimbursement for mental health services will be in accordance with the RBRVS schedule established by the Department. Claims must be submitted on a CMS-1500 form. Refer to the Physician-Related Services manual for additional billing instructions.

A family therapy session must not be billed under more than one family member’s Medicaid number. The family member must be Medicaid-eligible on the date of service.

Medicaid covers inpatient professional counselor services as part of the inpatient payment rate in the following circumstances:

When services are provided by a professional counselor who is employed by the hospital or under contract with the hospital involving consideration; and

When services are part of discharge planning as required in 42 CFR 482.21(b) or other services,such as group therapy, which are required as part of licensure or certification of the hospital.

All other inpatient services provided by a professional counselor are a benefit, up to the limits specified in this manual.

Inpatient Psychiatric Services

(for persons age 18 to age 21)

Inpatient Psychiatric Hospitalization
Inpatient psychiatric services are services provided in an inpatient hospital facility. A Certificate of Need (CON) is not required for persons who are age 18 to 21 years of age.
Prior authorization is not required prior to the member’s admission to inpatient psychiatric services.

Billing/Reimbursement
Payment for inpatient psychiatric services provided outside the state of Montana will be made only under the conditions specified in ARM 37.86.2801. Reimbursement for inpatient psychiatric services provided to Montana Medicaid members in facilities located outside the state of Montana will be as provided in ARM 37.86.2947.

Targeted case management services for adults (age 18 and older) with SDMI are case management services provided by a licensed mental health center in accordance with these rules and the provisions of Title 50, Chapter 5, Part 2, MCA.

A member may temporarily receive case management services from more than one case management provider. Refer to ARM 37.86.3305 for the criteria.

Definition
Targeted case management is defined as services that assist individuals eligible in gaining access to needed, medical, educational, and other services.

Covered Services and Requirements
Case management activities for adults with severe and disabling mental illness include the following assistance:

Comprehensive assessment and reassessment at least once every 90 days of an eligible member to determine service needs, including activities that focus on needs identification determination of the need for any medical, educational, social, or other services.

These assessment activities include the following:

Taking member history;

Identifying the needs of the individual, and completing related documentation; and

Gathering necessary information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to make a complete assessment of the eligible member.

Development (and periodic revision) of a specific care plan based on the information collected through the assessment that:

Specific goals and actions to address the medical, social and educational, and other services needed by the eligible member;

Includes activities such as ensuring the active participation of the eligible member and working with the member (or the member’s authorized healthcare decision maker) and others to develop those goals; and

Identifies a course of action to respond to the assessed needs of the eligible member.

Referral and related activities (such as making referrals and scheduling appointments for the member) to help the eligible member obtain needed services, including activities to help link the member with medical, social and educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan; and

Monitoring and follow-up activities, including activities and contacts to ensure that the care plan is effectively implemented and addresses the needs of the eligible member. Activity may be with the member, family members, service providers, or other entities or members and conducted as frequently as necessary, and at least once every 90 days, to help determine whether the following conditions are met:

Services are being furnished in accordance with the member’s care plan;

Services in the care plan are adequate to meet the needs of the member;

There are changes in the needs or status of the eligible member. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

Case management may include contacts with non-eligible members that are directly related to the identification of the eligible member’s needs and care, for the purpose of helping the eligible member access services, identifying needs and supports to assist the eligible member in obtaining services, providing case managers with useful feedback, alerting case managers to changes in the eligible member's needs, and averting crisis.

Case management does not include the following:

Non-Medicaid individuals can receive outreach, application, and referral activities;however, these activities are not allowable as case management services, rather they are an administrative function.

Direct medical services including counseling or the transportation or escort of members;

Duplicate payments that are made to public agencies or private entities under the State Plan and other program authorities;

The writing, recording, or entering case notes for the member’s file;

Coordination of the investigation of any suspected abuse, neglect, and/or exploitation cases;

Travel to and from member activities; and

Any service less than 8 minutes duration if it is the only service provided that day and any service that does not incorporate the allowable targeted case management components, even if written into the individualized care plan.

Provider Requirements
All providers of service must maintain records which fully demonstrate the extent, nature, and medical necessity of services and items provided to Montana Medicaid members. The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements. Refer to ARM 37.85.410 for medical necessity criteria and ARM 37.85.414 for record keeping and documentation requirements.

TCM for adults with SDMI must be provided by a licensed MHC with a license endorsement permitting the MHC to provide TCM. Licensed MHCs that have an endorsement to provide TCM services must enroll with Montana Medicaid as a TCM provider of mental health services before any case management claims can be paid. MHCs providing TCM services to adults with SDMI must have a program supervisor and employ case managers who have a Bachelor’s degree in a human services field with at least one year of full-time experience serving individuals with SDMI. Individuals with other educational background, who have developed the necessary skills, may also be employed as case managers. The MHC case management position description must contain equivalency provisions. The availability of case management services may not be made contingent upon a member’s willingness to receive other services.

Billing/Reimbursement
TCM services for adults with SDMI will be reimbursed according to the Department’s fee schedule. The Montana Medicaid program will not pay more than one provider for intensive case management services for the same period of time for the same member.

Case managers must inform eligible individuals they have the right to refuse case management at the time of eligibility determination and annually thereafter at the time of reassessment; and providers must document in the case record that the individual has been informed and if the individual has refused services. Refer to ARM 37.85.410 and ARM 37.85.414.

All providers of service must maintain records which fully demonstrate the extent, nature, and medical necessity of services and items provided to members. The records must support the fee charged or payment sought for the services and items and demonstrate compliance with all applicable requirements. The amount, duration, and scope of the case management activities must be documented in a member’s person centered plan of care which includes case management activities prior to and post-discharge, to facilitate a successful transition to the community.

The Department will pay the lower of the provider’s actual submitted charge or the Department’s fee schedule for case management services for adults with SDMI. Case management services for adults will be reimbursed under the following procedure code by Montana Medicaid. They must be billed on the CMS-1500:

Valid ICD-9-CM diagnosis codes must be used for dates of service on or before September 30, 2015. For dates of service October 1, 2015 and after, ICD-10-CM diagnosis codes must be used. Failure to use valid diagnosis and procedure codes will result in claims denial. DSM codes are not valid in the Medicaid claims processing system.

Pharmacy Services

Medicaid Pharmacy Program
There is no change in processing pharmacy claims for Medicaid-eligible members. Refer to the Medicaid Prescription Drug Program manual for billing and reimbursement instructions.

To request prior authorization, providers must submit the information asked for on the Request for Medicaid Drug Prior Authorization form to the Drug Prior Authorization Unit.

The prescriber (e.g., physician) or pharmacy provider may submit requests by mail, telephone, or fax to:

Requests will be reviewed and approvals or denials will be made, in most cases, immediately. Decisions on requests requiring further peer review because of unusual or special circumstances will be made within 24 hours. Requests received after the Drug Prior Authorization Unit’s regular working hours of 8 a.m. to 5 p.m., Monday through Friday or on weekends or holidays will be considered to be received at the start of the next working day.

If an after-hours, weekend, or holiday request is for an emergency situation, an emergency 72-hour supply may be dispensed by using 3 in the Days Supply field and Medical Certification Code 8 in the PA/MC code field. Payment will be authorized for these emergency supplies.

To receive payment for drugs requiring prior authorization, pharmacies must obtain approval from the Drug Prior Authorization Unit prior to dispensing the drug.

Coverage
Prescriptions are limited to a 34-day supply. Refills may be dispensed after 75% of a previous dispensing of the same prescription has been used, if taken according to the doctor’s orders. Exceptions to this refill rule must be authorized by the Department.

Reimbursement
Reimbursement information is available in the Prescription Drug Program manual.

Billing
Billing information is available in the Prescription Drug Program manual. If you have questions or experience problems, call Montana Provider Relations:

1 (800) 624-3958 (In/Out of state)
(406) 442-1837 (Helena)

Copayment
Preferred generic drugs
Preferred brand drugs only with generic available
Brand name drugs with no generic
Generic non-preferred
Non-preferred brand
No copayment for Clozaril and Clozapine

The Medicaid copayments are 5% of the allowable amount between $1 and $5 with a maximum cost share of $5 per prescription, and $25 per month.

Preferred products are drugs listed on the formulary for which the State of Montana has a rebate agreement with the drug manufacturer.

Indian Health Service (IHS)
Indian Health Service providers may be reimbursed for mental health services for Medicaid members. Indian Health Service providers should bill using the mental health encounter Revenue Code 513 or the inpatient physician services Revenue Code 987.

Administrative Rules of Montana (ARM)

The rules published by the executive departments and agencies of the state government.

Adult

A person who is 18 years or older. (Note: Children’s Mental Health continues to cover a person 18–21 who is enrolled in secondary school.)

Adult Day Treatment

A program that, in accordance with mental health center license requirements, provides a variety of mental health services to adults with severe disabling mental illness.

Allowed Amount

provider for a healthcare service as determined by Medicaid or another payer. Other cost factors (such as cost sharing, TPL, or incurment) are often deducted from the allowed amount before final payment. Medicaid’s allowed amount for each covered service is listed on the Department fee schedule.

Assignment of Benefits

A voluntary decision by the member to have insurance benefits paid directly to the provider rather than to the member. The act requires the signing of a form for the purpose. The provider is not obligated to accept an assignment of benefits. However, the provider may require assignment in order to protect the provider’s revenue.

Authorization

An official approval for action taken for, or on behalf of, a Medicaid member. This approval is only valid if the member is eligible on the date of service.

Centers for Medicare and Medicaid Services (CMS)

Administers the Medicare program and oversees the state Medicaid programs.

Clean Claim

A claim that can be processed without additional information from or action by the provider of the service.

Code of Federal Regulations (CFR)

Rules published by executive departments and agencies of the federal government.

Coinsurance

The member’s financial responsibility for a medical bill as assigned by Medicaid or Medicare (usually a percentage). Medicaid coinsurance is usually 5 percent of the Medicaid allowed amount, and Medicare coinsurance is usually 20 percent of the Medicare allowed amount.

Community-Based Psychiatric Rehabilitation and Support

Services provided in home, school, workplace, and community settings for adults with severe and disabling mental illness and youth with serious emotional disturbance.

Services are provided by trained mental health personnel under the direction of and according to individualized treatment plans prepared by licensed professionals. The services are provided outside of normal clinical or mental health program settings and are designed to assist individuals in developing the skills, behaviors, and emotional stability necessary to live successfully in the community.

Community-based psychiatric rehabilitation and support services are provided on a face-to-face basis with the member, family members, teachers, employers or other key individuals in the member’s life when such contacts are clearly necessary to meet goals established in the member’s person centered plan of care.

Copayment

The member’s financial responsibility for a medical bill as assigned by Medicaid (usually a flat fee).

Cost Sharing

The member’s financial responsibility for a medical bill assessed by flat fee or percentage of charges.

Crisis Intervention Services

A program that, in accordance with mental health center license requirements, provides emergency short-term 24-hour care, treatment and supervision in a crisis intervention stabilization facility for persons age 18 or older with mental illness experiencing a mental health crisis.

Crossovers

Claims for members who have both Medicare and Medicaid. These claims may come electronically from Medicare or directly from the provider.

Dialectical Behavior Therapy (DBT)

A treatment designed specifically for individuals with self-harm behavior, such as self-cutting, suicide thoughts, urges to suicide, and suicide attempts. It is based on a bio-social theory that states that problems develop from the interaction of biological factors (physiological makeup) and environmental factors (learning history), which together create difficulty managing emotions. Core treatment techniques are problem solving, exposure techniques, skills training, contingency management, and cognitive modification. The four primary modes of treatment are individual therapy, group skills training, and phone coaching, along with therapist consultation.

Department

The Montana Department of Public Health and Human Services or its agents, including but not limited to parties under contract to perform audit services, claim processing, and utilization review.

DPHHS, State Agency

The Montana Department of Public Health and Human Services (DPHHS or Department) is the designated State Agency that administers the Medicaid program. The Department’s legal authority is contained in Title 53, Chapter 6, MCA. At the Federal level, the legal basis for the program is contained in Title XIX of the Social Security Act and Title 42 of the Code of Federal Regulations (CFR). The program is administered in accordance with the Administrative Rules of Montana (ARM), Title 37, Chapter 86.

Emergency Services

Those services which are required to evaluate and stabilize a medical condition manifesting itself by acute symptoms of sufficient severity (including pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or unborn child) in serious jeopardy, serious impairment to bodily function or serious dysfunction of any bodily organ or part.

Experimental

A noncovered item or service that researchers are studying to investigate its effect on health.

Fiscal Agent

Conduent is the fiscal agent for the State of Montana and processes claims at the Department’s direction and in accordance with ARM 37.86 et seq.

Foster Care for Adults with Severe Disabling Mental Illness

A supervised living environment in a licensed foster home with support services by mental health professionals.

Illness Management and Recovery

An evidence-based practice that gives consumers information about mental illnesses and coping skills to help them manage their illness, develop goals, and make informed decisions about their treatment.

Inpatient Hospital Psychiatric Care

Hospital-based active psychiatric treatment provided under the direction of a physician.

Institution for Mental Diseases

A hospital, nursing facility, or other facility with more than 16 beds which the Department has determined is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services.

An institution for the mentally retarded, including an intermediate care facility for the mentally retarded, is not an institution for mental diseases.

An institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

In making a determination of whether an institution is an institution for mental diseases, the Department shall consider the guidelines set forth in Subsection C of Section 4390 of the State Medicaid manual, but no single guideline or combination of guidelines shall necessarily be determinative.

Intensive Community-Based Rehabilitation Facility

An adult mental health group home that provides medically necessary rehabilitation services to adults with severe and disabling mental illness who have a history of institutional placements due to mental illness and a history of repeated unsuccessful placements in less intensive community-based programs.

In-Training Practitioner Services

Services provided under the supervision of a licensed practitioner by an individual who has completed all academic requirements for licensure as a psychologist, clinical social worker, or licensed professional counselor, and is in the process of completing the supervised experience requirement for licensure.

The in-training practitioner services must be supervised by a licensed practitioner in the same field, and, other than licensure, the services are subject to the same requirements that apply to licensed practitioners. In-training practitioner services are only available through licensed mental health centers.

Medicaid

A program that provides healthcare coverage to specific populations, especially low-income families with children, pregnant women, disabled people, and the elderly. Medicaid is administered by state governments under broad Federal guidelines.

Member

An individual enrolled in a Department medical assistance program.

Mental Health Center Services

Adult day treatment services, community-based psychiatric rehabilitation and support respite care, in-training practitioner services and the therapeutic component of crisis intervention services, foster care for mentally ill adults, and mental health group home services and programs of assertive community treatment, as defined in ARM 37.88.901.

Mental Illness

A mental illness listed as a mental disorder in the current edition of the Diagnostic and Statistical Manual of Mental Diseases but does not include mental retardation, senility, and organic brain syndrome.

Mental Health Group Home Services

A supported living environment provided under a group home endorsed mental health center license and providing independent living and social skills development services.

Mental Health Services Plan (MHSP)

This plan is for individuals who have a severe and disabling mental illness (SDMI), are ineligible for Medicaid, and have a family income that does not exceed an amount established by the Department.

Nursing Facility Services

Services defined in ARM 37.40.302, but not including intermediate care facility services for the persons with intellectual disabilities.

Patient Day

A whole 24-hour period in which a person is present and receiving inpatient psychiatric services or nursing facility services, regardless of payment source. Even though a person may not be present for a whole 24-hour period on the day of admission or the day of death, such day will be considered a patient day. Subject to the limitations and requirements of ARM 37.88.1106, therapeutic home leave days are patient days. The day of discharge is not a patient day for purposes of reimbursement.

Practitioner

Practitioner Services

Services provided by a practitioner who could be covered and reimbursed by the Montana Medicaid program if the individual practitioner were enrolled in the program and provided the services according to applicable Medicaid requirements.

Prior Authorization

The approval process required before certain services or supplies are paid by Medicaid. Prior authorization must be obtained before providing the service or supply.

Private-Pay

When a member chooses to pay for medical services out of his or her own pocket.

Program of Assertive Community Treatment (PACT)

A self-contained clinical team that:

Provides needed treatment, rehabilitation and support services to identified members with severe disabling mental illness;

Minimally refers members to outside service providers;

Provides services on a long-term basis;

Delivers 75% or more of team service time outside program offices;

Serves individuals with severe disabling mental illness (SDMI) who are at least18 years old, have severe symptoms and impairments not effectively treated by other available, less-intensive services, or who have a history of avoiding mental health services;

Provides psychiatric services at the rate of at least 20 hours per week for each70 persons served; and

Maintains a ratio of at least 1 staff person,not including the psychiatrist, for each9 persons served.

Assertive community treatment teams must be approved by the Addictive and Mental Disorders Division.

Provider or Provider of Service

An institution, agency, or person having a signed agreement with the Department to furnish medical care, goods, and/or services to members, and eligible to receive payment from the Department.

Relative Value Scale (RVS)

A numerical scale designed to permit comparisons of appropriate prices for various services. The RVS is made up of the relative value units (RVUs) for all the objects in the class for which it is developed.

Relative Value Unit (RVU)

The numerical value given to each service in a relative value scale.

Remittance Advice

The results of claims processing (including paid, denied, and pending claims) are listed on the remittance advice.

Resident

A person admitted to the provider’s facility who has been present in the facility for at least one 24-hour period.

Resource-Based Relative Value Scale (RBRVS)

A method of determining physicians’ fees based on the time, training, skill, and other factors required to deliver various services.

Retroactive Eligibility

When a member is determined to be eligible for Medicaid effective prior to the current date.

Standard Medicaid

All Medicaid Members are eligible for services in the Standard Medicaid Package if the services is medically necessary. See the General Information for Providers manual.

Services that assist members eligible in gaining access to needed medical, social, educational, and other services.

Third Party Liability (TPL)

Any entity that is, or may be, liable to pay all or part of the medical cost of care for a Medicaid/HMK Plus, MHSP, or HMK/CHIP member.

End of Appendix A: Definitions and Acronyms Chapter

Index

Previous editions of this manual contained an index.

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